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Glossary

Indications

Bicondylar fractures of the head of the proximal phalanx may be T-shaped,
with a long or a short T.
Another pattern of fracture is a combination of a long oblique fracture
separating one condyle, together with a short oblique, or transverse, fracture
separating the other condyle (sometimes called “lambda” fractures, because of
their resemblance to the Greek letter “λ“).
Lag screw fixation is indicated both for the short T-shaped and the lambda
fractures.
Typically these fractures are the results of sports injuries, due to axial load
combined with lateral angulation of the finger.
Condylar fractures tend to be very unstable and should be treated operatively.
If nonoperative treatment is attempted, secondary displacement is likely,
leading to angulation of the finger.

CaveatThese fractures are rare, but difficult to treat. There is an
increased risk of joint stiffness resulting from these fractures.

It is wise to use magnifying loupes in these procedures. Gentle and
precise handling throughout the procedure is mandatory.

Anatomical reduction mandatory

Articular fractures must be reduced anatomically. Otherwise, the articular
cartilage may be damaged, leading to painful degenerative joint disease and
digital deformity.
This illustration shows how even slight unicondylar depression may lead to
angulation of the finger.

Visualization of the fracture

In order to gain a better view of the fracture, use a syringe to irrigate
out blood clot with a jet of Ringer lactate.
Gently explore the fracture site to assess its geometry, using a dental pick.
The pick can also be used carefully to reduce small fragments. Take great care
to avoid comminution of any fragment.
It is important to maintain the vascularity of tiny fragments attached to the
collateral ligament, in order to avoid osteonecrosis.

Indirect reduction

Reduction starts with traction in order to restore length.
Lateral pressure, exerted by the surgeon’s thumb and index finger, will then
reduce the fracture.
Confirm reduction using image intensification.

Location of the drill holes

On the lateral intraarticular aspects of the condyles, there is a small
ridge on each side. These are uniquely suited for screw placement, as the
screws can be buried deep to the edge of the cartilage without violating the
joint surface and avoiding causing irritation.

Drilling

Hold the condyle in the reduced position with a dental pick. Some surgeons
use pressure from the drill guide to hold the reduction during drilling.
Drill a gliding hole as perpendicularly to the fracture plane as possible at
the site of this ridge, using a 1.0 mm drill bit for a 1.0 mm screw.
Use a 0.8 mm drill bit to drill a thread hole in the opposite fragment, just
through the far (trans) cortex.
With very small fragments, it may be advisable to drill with manual rotation of
the bit, rather than a powered driver.

Pearl: use drill bit for temporary fixationLeave the drill bit in the drill hole to preliminarily hold the fragment in
place.

Planning the second screw track

Drill the second condyle

In the second condyle, drill a gliding hole as perpendicularly to the
fracture plane as possible, using a 1.0 mm drill bit for a 1.0 mm screw.
Use a 0.8 mm drill bit to drill a threaded hole in the opposite fragment, up to
the far (trans) cortex.